Mental health Clinical

The role of the nurse in eating

disorder recovery
Primary care nurses must be able to treat patients with these conditions, writes Nicola Davies

ADOBE
The late teenage years are the most common age to develop an eating disorder

A
2015 report reveals that
more than 725,000 people
in the UK are affected by
eating disorders such as
anorexia, bulimia, and binge-
eating disorder.1 In recognition
of the seriousness of these
conditions, the government
announced earlier this year
that it was committing £150
million to improve access to
mental health services for
young individuals affected
by eating disorders.2
In whatever form an eating
© 2017 MA Healthcare Ltd
emotional and social wellbeing
of the patient must all be
considered. Nurses play a vital
role in eating-disorder recovery
through the delivery of person-
centred care and the provision
of a supportive, therapeutic
relationship.
Identifying eating
disorders in primary care
Nurses are often the initial
point of entry to care for
people with eating disorders
and can therefore be
important in establishing
the foundations for recovery,
especially with those patients
who may not realise they
have a problem.
Possessing the skills to
identify potential patients is
crucial. It requires a breaking
down of the myths associated
with eating disorders. For
example, not everyone with
an eating disorder will present
as emaciated. Even people
with anorexia start on a
continuum of illness and can
be identified before reaching
a severely low body weight.
At times, people with eating
disorders are not convinced
that they have a condition
that needs treatment, or are
ashamed to volunteer personal
information to a health
professional. Nurses who have
familiarity with the clinical,
psychological and behavioural
symptoms of eating disorders
can better assist physicians
during physical and mental
health assessments. An

disorder manifests, recovery understanding of eating

is extremely complex and
those affected cannot achieve
it in a vacuum. To achieve
successful and long-lasting
recovery, the physical,
disorder treatment guidance
“Nurses are often the initial point of entry will also help nurses
to care for people with eating disorders, so decide whether it might be
appropriate to recommend
can establish the foundations for recovery” an intervention.

www.independentnurse.co.uk 20 March 2017 | Independent Nurse | 25

Downloaded from magonlinelibrary.com by 129.096.252.188 on April 13, 2019.

Eatingdisorders.indd 25 18/04/2017 09:41

 Clinical Mental health

Typically, patients have
clinical presentations such
as nutritional imbalances
(above/below average body
mass index (BMI), pale
mucous membranes in the
eyes, oedema, hair loss, and
cardiac irregularities) and
body fluid deficiency (dry
skin, increased body
temperature and blood
pressure, dehydration,
physical weakness, and
electrolyte imbalance).4
According to the National
Institute for Health and Care
Excellence (NICE) Guideline
on the clinical management
of eating disorders, there are
some target groups in primary
care and non-mental health
settings who are suitable for
eating disorder screening.
These include:
zz young women with below
average BMI
zz individuals consulting
about their weight
despite being within the
normal weight range
zz patients with
gastrointestinal problems
zz females with amenorrhoea
(absence of menstruation)
zz young people exhibiting
poor growth
zz people with signs
of starvation or
repeated vomiting.
Even adolescents diagnosed
with Type 1 diabetes who show
poor medication adherence
must be screened because
some may avoid taking insulin
Box 2
Nurses can monitor the following psychological markers among
patients:4
zzDisturbed thought processes – impaired decision-making, abnormal
sleeping patterns, or failure to recognise fatigue or hunger.
zzDistorted body image – consistently considers self to be ‘fat’ despite
normal weight or emaciated appearance, or is overly dependent on
the opinions of others.
to reduce calorie intake.5 This
is also known as diabulimia.
A holistic approach to
eating disorder treatment
The level of risk for engaging in
eating disorder behaviours may
increase when a patient starts to
confront the deep emotional
reasons for their condition, and
when gaining weight after
significant weight loss.6
Although eating disorders
manifest physically, the causes
are often psychological and
therefore nurses must observe
and support patients as they
confront deeper emotional
issues. Indeed, physical,
emotional, cognitive and social
aspects of treatment need to be
taken into consideration when
working with this patient group.
A holistic approach to
nursing is congruent with the
most common types of eating
disorder treatments such as
cognitive-behavioural therapy
(CBT), dialectical-behaviour
therapy (DBT), family therapy,
group therapy, and art therapy,
among others.
Since recovery involves
patients having to face their
deepest, most painful, and
traumatic thoughts and
emotions, supporting them
as they go through treatment
can be emotionally challenging
for nurses. This emotional
challenge can be exacerbated
when the patient has also been
diagnosed with Obsessive
Compulsive Disorder (OCD),
depression, or substance abuse,
as these may require more
intensive one-to-one support.
As this might take nurses
out of their comfort zone or
clinical remit, worksheets are
available for nurses to use in
efforts to help patients
challenge and overcome their
obsessive and ritualistic
behaviours and to adopt
a more flexible perspective in
day-to-day life.6 These can be
supplemented by nurses
familiarising themselves with
the detailed guidelines and
resources offered by NICE.5
Furthermore, learning
motivational interviewing
techniques can help facilitate
communication with those
who might be resistant to
discussing topics related to
food, weight, and recovery.
Such techniques can help
develop the skills of empathic
understanding, rolling with
resistance, and gently assisting
patients to make their own,
autonomous decision to
work towards recovery. Often,
the aim is to help patients
learn new and healthier ways
of coping, and nurses can
achieve this through a mix of
emotional support, education,
and signposting.
Assisting patients to remain
strong and adhere to treatment
requires nurses to develop
a relationship that is caring,
empathetic and trusting, and
in line with the person-centred
approach to care. Patients
affected by eating disorders
require individualised support
to better understand their
condition, rediscover their
identity, learn to accept
themselves, enhance a positive
body image and sense of self-
worth, and achieve a balance
in their lives so that they can
move towards better health
and wellbeing.
Box 1
zz
One in 250 females and one
in 2,000 males will develop
anorexia nervosa at some
point in their life.
zz
Bulimia is two or three times
more likely than anorexia.
zz
90% of those suffering from
bulimia are women.
zz
Anorexia typically develops at
age 16 or 17 and bulimia
at age 18 or 19 (although
either can start much earlier
or later).3
nurses, so offering advice on
where to seek long-term
support is essential and shows
genuine care for the patient’s
future recovery.
The evolving role of nurses
in the stages of recovery
General practitioners have
a duty to provide the initial
assessment and to coordinate
care, which may include
emergency psychiatric or
medical attention.5 However,
part of adopting a holistic
approach is providing
multidisciplinary care.
Treatment requires
collaboration between many
health-care professionals,
including physicians, nurses,
nutritionists, therapists/
counsellors, as well as the
family members.
Referral to secondary care
facilities is crucial for the
prevention of relapse following
treatment. Primary care nurses,
therefore, require training in
recognising the physical and
emotional symptoms that may
indicate an eating disorder so
that they can make referrals
to other health facilities that
can assist in addressing
comorbidities and ensuring
that patients get comprehensive
© 2017 MA Healthcare Ltd

zzImpaired relationships with parents – the presence of family conflict, This kind of support
communication difficulties, or having poorly defined family roles. needs to be consistent and
zzKnowledge deficit – has clear misconceptions about current health-care providers ideally
disordered eating behaviours and their effect on health, or is need to be able to commit to
preoccupied with fear of obesity. being in it for the long-haul.
This isn’t always possible for
clinical attention.
Throughout secondary care
treatment, nurses will need to
attend to medical treatment
priorities such as correcting
electrolyte/fluid imbalances

26 | Independent Nurse | 20 March 2017 www.independentnurse.co.uk

Downloaded from magonlinelibrary.com by 129.096.252.188 on April 13, 2019.

Eatingdisorders.indd 26 18/04/2017 09:41


and ensuring adequate
nutritional intake. In addition,
they will need to assist patients
to develop a more realistic
and self-affirming body image
and help educate family
members on their role in
recovery maintenance.
The road to recovery from
an eating disorder is a long
one. Clearly, as patients’
progress from awareness,
diagnosis, treatment, and then
to recovery maintenance,
nurses provide an evolving
type of support and therapeutic
relationship that can have a
good influence on the patient’s
health outcomes. In particular,
nurses can offer surveillance
and flexibility towards the
patient’s changing needs.7
In one study, patients
recovering from anorexia
identified three key roles of
nurses throughout treatment: 8
zz Structure provider
zz Role model
zz Support system
© 2017 MA Healthcare Ltd
www.independentnurse.co.uk
Eatingdisorders.indd 27
During the early stages of
treatment when patients are
still new to recovery, they
look to nurses to provide them
with a highly structured
environment, which sometimes
involves nurses making food
and behavioural decisions on
their behalf. While this might
not be an ongoing issue for
primary care nurses, they may
still be required to offer
decisive advice on these areas.
Here, it is imperative that
nurses offer such advice with
a clear message that patients
have the power to make these
decisions themselves.
As treatment progresses,
patients eventually grow to
appreciate nurses who act as
role models and educate them
in how to normalise their diet
and involvement in social
activities. Towards the end
of treatment, nurses become
more of a support system,
encouraging the patient to
move forward autonomously,
while providing them with
guidance on where to seek help
if it is needed.
Ultimately, there are
different stages to eating
disorder recovery and nurses
can benefit from learning how
to discern at which stage an
individual is situated so that
they can adapt their role
according to what the patient
might need in the moment.
From awareness of the
eating disorder to recovery
maintenance, the role of the
primary care nurse evolves,
but what doesn’t change is the
positive influence nurses can
have on those with an eating
disorder. With the skills of
listening, empathy, adaptability
and communication, primary
care nurses can assist in
identifying at-risk individuals
and optimising the delivery
of a multidisciplinary and
holistic approach to care. IN
Dr Nicola Davies, health psychologist,
and freelance medical writer
Downloaded from magonlinelibrary.com by 129.096.252.188 on April 13, 2019.
Mental health Clinical
Please comment online at
www.independentnurse.co.uk, email
IN@markallengroup.com or
tweet @IndyNurseMag
References
1. BEAT. The costs of eating disorders: social,
health and economic impacts. 2015. https://
www.b-eat.co.uk/assets/000/000/302/The_
costs_of_eating_disorders_Final_original.
pdf?1424694814
2. Prime Minister’s Office. Prime Minister pledges
a revolution in mental health treatment. 2016.
https://www.gov.uk/government/news/prime-
minister-pledges-a-revolution-in-mental-health-
treatment.
3. NHS. Eating disorders. 2015. http://www.nhs.
uk/conditions/eating-disorders/pages/introduc-
tion.aspx
4. Vera M. 7 Eating Disorders: Anorexia & Bulimia
Nervosa Nursing Care Plans. 2013. http://nurse-
slabs.com/7-eating-disorders-anorexia-bulimia-
nervosa-nursing-care-plans/
5. NICE. Eating disorders in over 8s; management.
2004. https://www.nice.org.uk/guidance/cg9/
chapter/1-Guidance#care-across-all-conditions
6. Davies N, Bacon E. Eating Disorder Recovery
Handbook: A Practical Guide to Long-Term Recov-
ery. Jessica Kingsley Publishers: London. 2016.
7. Love CC, Seaton H. Eating disorders. Highlights
of nursing assessment and therapeutics. Nurs Clin
North Am. 1991; 26(3):677-97.
8. van Ommen J, Meerwijk EL, Kars M et al. Effec-
tive nursing care of adolescents diagnosed with
anorexia nervosa: the patients’ perspective. J Clin
Nurs. 2009; 18(20):2801-8.
20 March 2017 | Independent Nurse | 27
18/04/2017 09:41